Complications of indwelling pleural catheter use and their management

Macy M S Lui, Rajesh Thomas, Y C Gary Lee, Macy M S Lui, Rajesh Thomas, Y C Gary Lee

Abstract

The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis, though complications can occur. Pleural infection affects <5% of patients, and is usually responsive to antibiotic treatment without requiring catheter removal or surgery. Pleural loculations develop over time, limiting drainage in 10% of patients, which can be improved with intrapleural fibrinolytic therapy. Catheter tract metastasis can occur with most tumours but is more common in mesothelioma. The metastases usually respond to analgaesics and/or external radiotherapy. Long-term intermittent drainage of exudative effusions or chylothorax can potentially lead to loss of nutrients, though no data exist on any clinical impact. Fibrin clots within the catheter lumen can result in blockage. Chest pain following IPC insertion is often mild, and adjustments in analgaesics and drainage practice are usually all that are required. As clinical experience with the use of IPC accumulates, the profile and natural course of complications are increasingly described. We aim to summarise the available literature on IPC-related complications and the evidence to support specific strategies.

Keywords: Empyema; Mesothelioma; Pleural Disease.

Figures

Figure 1
Figure 1
CT images of a patient with mesothelioma who developed catheter tract metastasis around his indwelling pleural catheter (IPC), which was in place for 5 months. The pain over the tumourous growth (arrow) was partially relieved with analgaesics, and he subsequently underwent external beam irradiation to the catheter tract metastasis, with good symptomatic control. His IPC was kept for drainage of malignant effusion.
Figure 2
Figure 2
This patient with a malignant pleural effusion was treated with an indwelling pleural catheter (IPC). After 4 months of drainage, he developed symptomatic loculations. The fluid could not be evacuated despite a patent catheter in the right pleural cavity. He was given intrapleural instillation of tissue plasminogen activator (tPA), with excellent effect. The post-treatment chest radiograph revealed an underlying trapped lung and a significant pleural rind of tumour.
Figure 3
Figure 3
Chest radiograph of a patient with mesothelioma and indwelling pleural catheter (IPC) for palliation of right pleural effusion. The drainage output reduced with minimal residual effusion after 10 months. Attempt was made to remove the IPC en bloc, but the part distal to the cuff adhered tightly to underlying tissue after freeing the cuff. A decision was made to sever the catheter close to the pleura. The IPC fragment (arrow) was retained without any problems in subsequent follow-up.
Figure 4
Figure 4
An indwelling pleural catheter (IPC) removed from a patient with mesothelioma. On inspection after removal, the lumen of the catheter was blocked by a string of fibrin clot (arrow), which could be pulled out intact from the catheter using a pair of forceps.

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